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FOR OFFICE USE: APPLICATION FOR SANITATION PERMIT <br /> � = <br />........................................... Permit No. .....-.........:..... <br /> (Complete in Triplicate) ' <br />:....................................................... 3 7 <br /> < Date Issued .�...."._..:...:. <br /> .......................... This Permit Expires 1 Year From Date Issued <br /> Application is hereby made to the San Joaquin Local Health District for a permit,to construct and install the work herein <br /> described. This application is made in compliance with C unty Ordinance No. 549 nd a 'sting Rules and Regulations: <br /> JOB ADDRESS/LOCATI � �... ... �r�`- f` `. ••.-.. ...._.............. NSUS TRACT ........................ <br /> Owner's Name ... ..,.... _. . ._ ._. _,. ..�. _�.... f.-..._..._. .............. <br /> . <br /> .... -- . --• . <br /> Address . City :..... <br /> .-.License # ...---.... . Phone <br /> ----- <br /> Contractor's Name ..... ............. ....................•-------------• .... ................ <br /> Installation will serve: Residence partment House C] Commercial ❑Traller Court 0 <br /> Motel ❑Other ...............:.......................... <br /> Number of living units:............ Number of bedrooms _. ...--Garbage Grinder ............ Lot Sze .....,..-_.............._....- <br /> Water Supply: Public System and name --------------------...................------- ---------.....----- ............... :..........Private <br /> Character of soil to a depth of 3 feet.- Sand Si It❑ Clay ❑ Peat❑ Sandy Loam C3 Cloy Loam ®� <br /> Hardpan ❑ Adobe 0 Fill Material _.......•... If yes,type ..:..:....................... <br /> (Plot plan, showing size of lot, location of.system in. relation to wells, buildings, etc.-must be placed on reverse side.)( N <br /> NEW INSTALLATION: {No septic tank or seepage pit permitted if public.sewer is available within 200 feet,) <br /> PACKAGE TREATMENT ( j SEPTIC TANK t j Size---------.•----•----.-••................ ....... Liquid Depth ................. <br /> Capacity"-_'................. Type..................... Material.----• ................ No. Compartments ........... <br /> Distance to nearest: Well ...................................Foundation ........................ Prop;.L-ine. ...................... <br /> LEACHING LINE ( j No. of Lines ------------------------ Len #h of each line.-................_-:. Total length ............................ <br /> 'D' Box ....: Type Filter Material .........,. - -Depth'Filler Material ..........................•--_.. .... <br /> I, <br /> Distance to nearest: Well ...........:.:..... <br /> ...... Foundation .._--_:--1...........,.�.. Property Line -------...----..-.----_- <br /> ......t_.._...._.. Diameter. Number;.: _..:'..': _.::. Rock Filled Yes ❑ No <br /> -------------- <br /> SEEPAGE FIT { � Depth ............:... ..._. <br /> Water TableDepth .Rock Size <br /> I , <br /> Distance to nearest: Well ......-°.._.•-- .......' .Foundation .................... Prop Line ............... _ <br /> REPAIR/ADDITION(Prev. Sanitation;Permit# ......... ................----------. .............. Date ....................................... <br /> Septic Tank (Specify Requirements) ....... .......... ------------ - -• ......... - . .. --• <br /> ----.._ -------......_ <br /> Disposal Field ,( pecify Requirements). _. _.:. ----------- -- - <br /> - - <br /> - - <br /> 3 ---- ----------------- <br /> (Draw existing and required addition on reverse side) <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin i <br /> County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- <br /> sed agents signature certifies the following: r _ <br /> "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner <br /> as to become subject to V4lorkmdn's'�Compentation laws,of California." <br /> Sig ......-- ...... Owner <br /> By ------ ---- ----­--------- ­--------­---------------- Title --------------....................:..................... ........... <br /> other than owner); <br /> FOR DEPARTMENT USE ONLY <br /> APPLICATION ACCEPTED BY ... .. _ ------------------------------ ---------- ------•--.. . <br /> DATE /.. .". `.3: .........-•--- <br /> IBUILDING PERMIT ISSUED ------.-.... !...--------- .......:..................................:....•----...-----------.......DATE ................ <br /> ADDITIONAL COMMENTS ........ ..........................................-.......................... <br /> . <br /> .................. ....... ....................................... <br /> F <br /> ....................... _ <br /> = ....------. -D --- - <br /> Final Inspection by: ...... �-------=---•--•-------..........-----....... I........ <br /> Dote J �� <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> z w AP- <br /> 13 24 _ ISR Rav 5M <br />